High Risk Care Coordinator

General Summary:

The High Risk Care Coordinator provides psychosocial support, care coordination, and serious illness guidance for high risk and medically complex patients in a value based primary care setting. This role focuses on patients with advanced chronic conditions, functional decline, frequent utilization, or complex social needs.

The coordinator collaborates with physicians, nurse case managers, and interdisciplinary teams to address barriers to care, support care transitions, facilitate advance care planning, and coordinate services across the continuum of care. The role integrates social work principles, care coordination, and end of life support to improve quality of life and reduce avoidable utilization

Supervisory Responsibilities:

General Requirements:

This position has no supervisory responsibilities.

All duties performed will be done accurately and in a timely manner.

The High Risk Care Coordinator supports population health outcomes by:

1. Reducing avoidable emergency visits and hospitalizations
2. Improving transitions of care and post discharge follow up
3. Increasing advance care planning and goals of care documentation
4. Facilitating appropriate use of palliative care and hospice services
5. Addressing social determinants of health impacting outcomes
6. Supporting patient engagement and care plan adherence
7. Conduct psychosocial and supportive care assessments for high risk patients
8. Provide emotional support, counseling, and guidance for patients and families
9. Identify and address social determinants impacting care and outcomes
10. Care Coordination and Transitions
11. Collaborate with physicians and care teams to develop and support individualized care plans
12. Coordinate referrals to community resources, behavioral health, home health, palliative care, and hospice
13. Support care transitions including hospital discharge and post acute follow up
14. Participate in interdisciplinary care management meetings
15. Facilitate advance care planning and goals of care discussions
16.  Educate patients and families on palliative care and hospice services
17. Provide supportive presence and guidance aligned with end of life care principles
18. Document assessments, interventions, and coordination activities in the electronic health record
19. Ensure compliance with HIPAA and organizational policies
20.  Support quality and population health initiatives
21. Maintain knowledge of community resources and supportive services
22. Participate in ongoing professional development
23. Support organizational goals related to value based care and patient outcomes
24. Perform other duties as assigned

Education and Training:

MSW preferred (completed or in progress), or MPH or bachelor’s degree in healthcare administration, Social Work, Public Health, or related field.

End of Life Doula Certification is preferred. Training in palliative care, hospice care, or serious illness communication preferred

Experience:

Experience in hospice, palliative care, care coordination, or healthcare operations preferred. Experience working in interdisciplinary teams. Familiarity with EHR documentation and healthcare compliance

Other Requirements:

Computer Skills: Skilled in use of computer/EMR systems. Knowledge of Word processing software, spreadsheet software, Internet, and database software.

Work Environment:

This role is primarily in an office environment, though there may be periods of time spent in clinic or construction environments depending on projects assigned. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.

Mental / Physical Requirements:

Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 20 lbs. without assistance. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.

Additional Information:

Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.

Other Duties As Assigned: